CCE Exam

THE CLINICAL COMPETENCY EXAMINATION (CCE)

Clinical Format

Objective

• The CCE is designed to assess the clinical competence – how the candidate applies his knowledge and clinical reasoning skills when presented with a range of clinical scenarios, and his abilities over a range of competencies in the family medicine curriculum (1. Communication skills and the patient-doctor relationship. 2. Applied professional knowledge and skills. 3.Population health and the context of family medicine. 4. Professional and ethical role. 5. Organizational and legal dimensions.)
• Candidates are expected to demonstrate the application of their clinical skills as well as their communication skills, including inter-professional and patient-centred communication and professional attitudes, in the context of each case.

Examination format

• Each CCE consists of nine cases – including four cases in the case discussion format involving the candidate discussing a case with the examiner, and five cases in the clinical encounter format when the candidate interact directly with a role player while the examiners observe and assesses his competency. It is possible that the proportion of case discussion to clinical encounter cases may vary in different examinations.
• Each case lasts 15 minutes with five minutes reading time. During the reading time candidates are provided with a case scenario and instructions.
• Each case presents with a number of competencies that are assessed as the case unfolds. Within each of the competencies, multiple criteria describe the performance expected at the level of Fellowship.
• Examiners rate the performance of the candidate in relation to the competency areas being assessed in the context of each case. Ratings are recorded on a four-point Likert scale ranging from “Competency not demonstrated”, “Competency not clearly demonstrated”, “Competency satisfactorily demonstrated” to “Competency fully demonstrated”.
• The number of competency criteria chosen depends on the contents of each case but usually 10-15 criteria are selected.

The ten clinical competencies for the CCE

The following are the ten clinical competencies for the CCE. Within each competency there are multiple criteria describing “competent at the level of Fellowship”, and for each criterion how to “perform consistently at the standard expected”.

Further details of the ten clinical competencies, the criteria for each competency, and indicators of performance consistently at the standard expected, are listed in our Clinical Competency Rubric which can be accessed here:

Clinical Competency Rubric of HKCFP

Candidate procedure

		Candidates must hand in their bags (other than medical bags) and any electronic devices at the administration desk.
		Candidates will be given name tags, time slot slips, rotation schedule and examination hall floor plan upon registration.
		A folder with candidate's instruction sheet and blank paper is placed on the sitting chair besides each examination room. Candidate must leave the folder on the chair before entering examination room. A same set of instruction is available inside examination room.
		Candidates have a maximum of 5 minutes to read the instructions before each station. Read the instructions carefully and identify what is/are the expected requirement/s in that particular station.
		Candidates may make notes on assigned blank paper during their reading time, which they can use and take into the examination room with them. Candidates are not allowed to take these note papers with them out of the examination room at the conclusion of each case.
		Candidate should enter the consultation room when notified by the alarm according to centralized timing.
		Candidate must give the right time slot slip to examiners upon entering the consultation room. And a short briefing will then be delivered by the examiner.
		Timers with audible alarm are not allowed during examination. Timers will not be provided during the examination. Timers in examination room are for examiner's reference only and may not be synchronized with centralised timing.
		Examiners may inspect anything that a candidate brings into the examination room, and may at their sole discretion forbid the admission to the room of any materials that they deem unsuitable.
		There will be no warning signals within the stations.
		Candidate may interact with role playing examiners, actor patients, real patients, equipment/ mannequins in the examination room.
		Examination findings, surgery tests and investigation results may be
	-	given verbally by the observing examiner in response to candidate's questions
	-	on a printed sheet to be handed to candidate
	-	performed by the candidate on real or role playing patients/examiners
	-	given as printed or photographic material (e.g. photos, ECGs, pathology, imaging)
		Candidate must leave the examination room immediately when signaled by centralized timing.

The two kinds of cases in the CCE

(1) CASE DISCUSSION CASES

• Candidates are given instructions and a case scenario during the five minutes. The case information is available to the candidates throughout the examination.
• The examiner asks a number of questions related to the case. New case scenarios for the same patient may be introduced as the questions go on.
• Timing is managed by the examiner and each question is allotted an approximate time.
• If the candidate does not answer the question asked or does not address a particular aspect of the question, the examiner may ask a prompting question.
• Examiners may also ask probing questions to find out more information if the response lacked details or to clarify what was said.

(2) CLINICAL ENCOUNTER CASES

• Clinical encounters involve candidate interacting with a role player while observing examiners observes and grades his performance.
• Candidates are given to read during the five minutes a case scenario and instructions of what tasks to perform during the examination. The case information and instructions are available to candidates throughout the case.
• The tasks may include, but not limited to, the following in different combinations:
  1. History taking – a comprehensive biopsychosocial history to be taken from the patient.
  2. A relevant and systematic physical examination and interpretation of findings
  3. Rational choice of investigations and its interpretation
  4. Formulates a list of differential diagnosis or problem list.
  5. Management of the patient, including pharmacological and non-pharmacological
  6. Dealing with the patient’s psychological, social, medico-legal, preventive, health or other issues.
• When communicating with the role player, candidates should avoid common errors such as inappropriate language and use of jargon, lack of empathy and a formulaic approach, and a paternalistic, instructional approach.
• Communication with the role player should be appropriate for the person and their needs. It is important for the candidate to demonstrate active listening and respond to the cues given by the role player.

Determination of a passing grade

• Candidates are scored by their examiners against a rubric unique to each case and based on the four point Likert competency scale above.
• There is also an “Examiner’s overall rating of the candidate” with a five point scale from “Clearly below standard”, “Below expected standard”, “Borderline”, “At expected standard” and “Above standard”.
• A pass mark for each case is determined at the completion of the exam using the borderline regression method based on the scores in all the five “Overall rating” categories. The pass mark for the exam equals the sum of the pass marks for each individual case.
• There is no need to pass a minimum number of cases to achieve a pass in the CCE, nor are there specific stations that one must pass.
• The pass mark may vary from examination to examination, as determined by standard setting techniques. There is no intention to pass or fail a fixed percentage candidates. Instead the intent is to make fair and appropriate pass-fail decisions. Those who meet reasonable competency criteria pass, and those who do not meet competency criteria fail.

Candidates can also access more information about the clinical competency examination from the member’s website of the Royal Australian College of General Practitioners, especially “Clinical Competency exam: support resources”. (Please note that financial membership of the RACGP is required for logging into the member’s website).